Patients Face Lethal Infections from CRE

It’s all over the news right now.  A new killer germ is here and it is spreading.  The new germ is called CRE which stands for Carbapenem-Resistant Enterobacteriaceae.  Boy, the spell check on my computer just had a stroke trying to figure out those words, and I have to admit all the blood drained out of my face when I first heard about CRE ten years ago.  But as usual, we need to step back and look at the facts to determine what is really going on.

The CDC has been warning us for 10 years that CRE is a REALLY bad guy, and that it is coming(I wonder if they ever get tired of being right all the time?).   It’s here and like all newly discovered antibiotic-resistant germs or MDROs; it took several years for it to cause enough trouble to be noticed.  So now it is in our face, we are afraid and wondering what we can do to protect ourselves and our patients.  Fear is a powerful survival instinct and is sometimes needed to jolt us to action.  We can’t however let it paralyze us.  So as in the past when faced with confusing and overpowering information coming from all directions, we will attempt to break it down so we can all understand.

First:  What is CRE?

The bacteria that belong to the Enterobacteriaceae family are very common. They include bugs like E.coli, Klebsiella and Enterobacter.  If these names sound familiar it’s because they live as normal flora (good guys) in our digestive system, but when they take up residence elsewhere they become bad guys and cause urinary tract and other common infections.  Normally these infections can be easily treated with antibiotics, but with the CRE group, most if not all antibiotics are ineffective.   Because of this antibiotic resistance, severe infections caused by CRE can kill up to half of the people who get them.  These infections are still rare, (we have only seen one here at CTRMC) but we can’t escape the fact that they can be impossible to treat.  Imagine having to fight a UTI with only your immune system.  Most people can do it, but it is a long, hard, and painful process.  Folks with weakened immunity can have serious issues.

Second:  Where did it come from?

It came from within. Because we all have these bacteria in our intestines, every time we take an antibiotic our normal flora is exposed to the effects just as the bad bacteria are, the more antibiotics, and the more exposure.  Each time our good bacteria struggle to grow back, they are a little more resistant to the drugs than before the exposure.  It’s a natural selection thing, the survival of the fittest.  Repeat over and over and over and it is easy to understand how our own good bacteria can become multi drug resistant over time.  As long as they stay where they belong, no harm no foul.  But when they get to places like the bladder, lungs or a wound and cause an infection… SURPRISE…. The infection can be difficult, or with some CRE, impossible to treat.  They can then be transmitted to others by contaminated hands, equipment, and the environment.

Third:  What else can CRE do?

Well, that’s the scary part.  Picture this; you are at a paint ballpark with a group from work.  Your team is getting creamed because they don’t all have the proper gear to defend themselves.  Your team is dropping like colorful flies all around you. You, however, have the gear and remember you have an extra gear in your car so you run get it. Everyone now has protection and your team goes on to win the challenge.  In this example, you are the CRE germ.  CRE has the ability to give its antibiotic fighting abilities to other kinds of bacteria and make them resistant to all the drugs as well.  Once these other germs have the gift, they hold on to it and pass it on to all their baby germs forever and ever amen.

Fourth:  Now that we all have headaches lets discuss what we can do about CRE.

Now that it is here, it will stay.  Just like MRSA, VRE and ESBL we must learn to control it, minimize its effects, and prevent transmission.  We can do this, we have the power! We can protect against CRE the same way we protect against other nasty bugs.  Know the enemy by understanding CREs epidemiology.  Always perform good hand hygiene and environmental cleaning.  Identify and isolate CRE infected patients quickly, and practice the judicial use of antibiotics.  Don’t use a bazooka to kill a fly.  When antibiotics are necessary, ask for the mildest one that will get the job done.  Take every pill as directed, don’t stash unused antibiotics and educate patients on proper antibiotic use as well.

The CDC recommends that facilities like ours who see CRE cases rarely, start looking for it now, and we have. Surveillance for CRE began at CTRMC two years ago and as previously stated only one case has been identified so far.  Infection Control and the microbiology laboratory work closely, so patients with all MDRO infections, including CRE can be identified ASAP and Contact precautions initiated.   Since we may not know for 2 or 3 days we are dealing with a CRE infection, those good ol’ Standard Precaution practices will provide protection while we wait.  Remember everybody fluid or moist body surface has infection transmission potential.  Since most CRE infections present as urinary tract infections, more respect needs to be paid to patient urine specimens.   A splash to your eyes when emptying a urinary catheter bag or bedpan takes on a whole new meaning (beyond just being really gross) because such a splash now could be deadly.   WEAR EYE PROTECTION.  These bugs have also been known to hang around in the environment and even colonize plumbing and ventilation systems.  The good news is that, so far, they are not hard to kill in the environment.  We just have to kill them everywhere they may hide.  Systems like the Zimek and processes like terminal cleaning will help us there.

Have you noticed that each time we are challenged with new antibiotic-resistant bacteria, it seems to be a little tougher and a little meaner than the one before?  CRE is no exception.  If you sense a pattern here, you are correct.  We can expect more of these bad guys and we can expect them to live up to our expectations.  Comfort can perhaps be found in the fact that we learn a little bit from every encounter with MDROs and are building an arsenal of practices and knowledge to keep humans at the top of the evolutionary tree.  As always, call us if you have any questions, and thanks for listening.  Doris Dimmitt, Hospital Epidemiologist March 2013.